Saturday, October 31, 2009

She is very interested in learning more about what we can do to improve our environment. When we fall sick, our immune system helps us to recover. How can we apply the lessons we learn from the immune system when trying to heal a world which has become sick ?

She needs to find a mentor to help her progress further, which is why I did some homework on how mentors can help students.

I found the book, The New Mentors and Proteges by Linda Phillips-Jones very interesting.

Linda makes some great points.

Everyone knows that finding a mentor can be very helpful. As Lindapoints out, a mentor helps by:

1. Advising on goals2. Providing encouragement3. Teaching new skills and knowledge4. Offering a role-model to emulate5. Opening doors by providing increased exposure and visibility6. Creating a bridge to maturity

Why do mentors do this ? What do they get out of it ? How does being a mentor help the mentor ?

1. They get more work done with your help2. They are awarded for spotting new talent3. They are achieving vicariously through you4. They are investing in your future5. They are repaying past debts

“You are checking your email as you sit here,” Topol said. “Checking the web when you are bored. In the future you will check in on your own vital signs heart, oxygen, temperature,” and so on. That’s not very far away from today — thanks to non-invasive band-aid like sensors, Topol said."

Friday, October 30, 2009

NotifierRx to Reduce Hostpital Readmissions | Audiopoint: "NotifierRx reduces expensive hospital readmissions by automating your pre and post op patient communication and follow-up through a two-way interactive system over any telephone. Instead of a series of simple pre-recorded messages, the NotifierRx platform automates patient interaction to ensure accountability made possible through this truly interactive system.

Each patient receives a series of personalized reminders and queries. Responses are collected from your patient and fed directly to your internal records. Through this interactive, voice-enabled platform, problems with patient compliance can be identified quickly triggering additional patient recommendations, notifying staff of assessment updates, and even automated scheduling and rescheduling.

NotifierRx provides immediate feedback to the patient and staff during a sequence of automated follow up calls."

I am very excited about the way voice and data are being cleverly married together to help to improve medical care !

Wednesday, October 28, 2009

Medicine In Translation | Psychology Today: "I see the doctor as a translator. For most people, medicine is a foreign country, with its own language, customs, and mores. My patients are immigrants to this country, and many feel very disoriented. My job, as their physician, is to translate this alien world for them, to help them acclimatize and hopefully thrive.

Jhumpa Lahiri used a beautiful phrase for the titular story of her marvelous first book: 'The Interpreter of Maladies.' Doctors, of course, fit this bill-we are constantly interpreting our patients' maladies-but we are also interpreting the greater culture of medicine.

Being a translator can often be burdensome. It is not enough, as a doctor, to assemble the clinical details, deduce a diagnosis, compose a treatment plan. You also have to be sure the patient understands it all-and that can be an infinitely harder and longer process."

Interview: Healthwise Founder, Don Kemper - Wellsphere: "We think there are three sources of information that people need. They need to have information from their doctors, information that has a good solid evidence base, and then they need to hear from other people who have been in similar situations.

The piece that we focus on is the information that is really documented by medical research. We are really trying to find the right ways to reach out to the 2.0 group, so that we can get those two sources of information collaborating on a more regular basis and I think that’s going to happen in many different ways."

1. Get the facts, explore options, and get answers to common questions.2. Compare options and read stories by people who faced a similar decision.3. Gauge their feelings and record their concerns.4. Assess which way they are leaning by using an interactive slider tool.5. Check how much they've learned and how confident they are about their decision.6. Print a summary of their answers and notes that can be shared with providers and loved ones."

Tuesday, October 27, 2009

I just saw a challenging patient. The wife had ovarian failure, and one of the treatment options we offered them was donor egg IVF. Her husband was quite comfortable with this option, but she flatly refused.

He just could not understand why she was being so stubborn. Isn't this a sensible option ? If she does not have her own eggs, what's wrong with borrowing someone else's ? What's the big deal - it's just an egg after all ! This way she will get to experience the pregnancy and will be able to bond with the baby. Since I am willing to pay for this expensive treatment, why is she objecting ? It will be our own baby - and no one else will know we have used donor eggs, so why is she refusing ?

I often see this dilemma, where the husband and wife cannot see eye to eye as to what treatment option they should select. It is true that men are from Mars and women are from Venus. He was using a purely logical approach, just like most men adopt, because they think of themselves as being problem solvers. Fix the problem, find a solution and move on !

However, women are equally smart and can figure out the solution using the same logic. They really do not need this kind of assistance, because they are capable of figuring it out for themselves.

What wives need from husbands is empathy and a shoulder to cry on. Not being able to have a baby with her own eggs was a major disaster for her. It was the loss of a dream - the death of a hope. However, her husband could not understand this and this upset her even more ! If he's so smart, why can't he understand the pain I am going through ? This means they kept on talking at cross-purposes and going around in circles without ever getting anywhere.

He needed to understand her stance by borrowing her perspective. He then needed to explain to her that he understood what her feelings were and could sympathise with what she was going through. He needed to talk to her about all her fears - both expressed and unexpressed. These included the following:

Will I be able to love a child who was born with donor eggs ?What if the child does not look like us ?Will I be able to be a good mom ?

She felt responsible for bringing up the baby and felt she needed answers to there key questions before she could agree. She felt her husband was being very immature , short-sighted and goal- focussed. Her worries were far more subtle.

It is true that women are far more complex than men - and the sooner we realise this, the better. ( I have been married for nearly 25 years and it took me a long time to figure this out, but I am happy to share my learning !) When women say No, they are not just being pig-headed, but often being far-sighted, because they are much better at anticipating problems. Most men prefer taking a - We'll fix it when we get to it approach, which many women find uncomfortable, because this involves a live baby whom they are bringing into the world !

I asked him a simple question. What if you had to use donor sperm ? What would your feelings be ?

Realisation finally dawned on him ! He could now appreciate some of the complex feelings his wife was having to struggle with. I don't know what they will finally decide, but I am sure they will have a more fruitful discussion now !

The commonest outcome of an IVF cycle is that the clinic makes good quality embryos, but these embryos do not implant , as a result of which the patient does not get pregnant.

When the embryos do not implant, why do we call it a failure ?

Infertile women often have low self esteem and pin a lot of their hopes and dreams on their IVF treatment cycle. When we use a word like failure, this is like stabbing another dagger through her broken heart. The word failed is loaded with meaning and emotions. When we call it a failure, the patient feels she has failed in her test. She feels she has failed in her role as a woman in society , by not being able to complete her family ; as a wife , by not being able to give her husband a child ; and as a daughter , by not being able to give her parents a grand child. This reinforces her feelings of low self-esteem and she feels even more inadequate and incompetent . She often blames herself and thinks that her body has rejected the embryos, which is why the IVF cycle failed.

I think we should stop using the word failure when the IVF cycle does not result in a pregnancy because it is such an emotionally charged word. After all, it's the cycle which failed, not the patient ! And even if the patient does not get pregnant, the IVF cycle usually does succeed in making embryos ! Isn't this an important milestone ? And each IVF cycle does give us invaluable information which helps us help the couple to move closer to their final goal !

When a couple does not get pregnant the first month they have sex, we don't say they have failed to make a baby ! Can we think of a kinder and more accurate term when the embryos do not implant after IVF ?

Monday, October 26, 2009

Patient often ask me to analyse their earlier IVF treatment cycles. Was the treatment provided correct ? Did the doctor do a good job ? Could he have done anything differently ? Was there a better option ? Why did the IVF cycle fail ?

When I asked a patient this question, his answer was - I did try to ask, but my doctor curtly told me - Don't ask me questions !

I was trying to figure out why a doctor would do so .

Many doctors get irritated by questions because they feel the questions are "stupid" and not worthy of their time or attention.

Others are very busy, and because they have to finish seeing another 10 patients in the next one hour, they are not inclined to answer questions, and are quite happy to delegate this to their assistant. This attitude is very common amongst hot-shot surgeons, who feel their time is very precious . They would rather be operating in the Operation Theater, rather than sitting and talking to patients and answering their questions!

Others feel threatened by a patient's questions. They think that the patient is questioning their authority and this puts them off. They can afford to get away with a brusque attitude because patients think they are powerless and helpless.

A good doctor will encourage a patient's questions. When a patient asks questions, he is doing so only because he wants to learn more about his treatment options - and if he cannot ask his doctor, whom can he ask ?

At Plus91, we have introduced many exciting new features into our software. These products are specifically targeted at doctors and clinics in the Indian Market. Here are some of the features we offer that are appreciated by doctors.

1. SMS and Email integration – This allows inexpensive communication with patients ! Today, all ofIndia communicates on the mobile , so why not doctors ?

2. Data Protection - Online automatic back up saves your data in case of a crash . You can also backup your entire PC onto an external hard disk provided by us. Keeping the data safe and secure has always been a priority , and we allow you to do this easily and painlessly !

3. Point and click interfaces - Simple graphical user interfaces makes learning easy and life simple for the doctor. A short learning curve ensures that the doctor and his staff can start using the software within minutes !

4. Online EMR – We allow doctors the ability to offer their patients records online for easy access. This is especially useful for patients from out of town or those who travel a lot.

5. Online Support and Updates – This means that doctors no longer need to wait for the technician or support engineer to arrive at the clinic. We can fix your problem online, instantly !

6. Structured Reporting – Every medical specialty needs to capture specific data. We have developed a huge library of customized templates for each specialty. These are already pre-loaded, so you can select what works best for you and start work from Day 1 !

7. Flexible customization. Each specialist has their own way of taking a history and recording data. We can customise each template, so that it fits your habits and workflow. This adaptability means the software learns your preferences and you don’t have to change anything you do !

8. Intelligent software which minimizes typing. We understand doctors hate looking at a keyboard and many are painfully slow typists. Plus91 has many clever features including memory and auto-complete, so you don’t have to keep on typing – Plus91 does this automatically for you, making date entry fast and efficient !

9. Ability to export data . Our export to excel feature is appreciated by Doctors ( and their CAs !) as it helps them to send their accounting figures to their CAs without any headache. Since we use XML and are HL7 compliant, all this data will be interoperable with other medical software packages !

10. Adding attachments – You can capture and attach videos, images and documents to the patient record, so the software allows you to do everything with one package !

Sunday, October 25, 2009

Penguin Problem in EMR Adoption | EMR and HIPAA: "Vince Kuraitis opened my eyes to a new term called the “Penguin Problem” and applying it to EMR adoption. Here’s the principle: Economists call it “The Penguin Problem” — No one moves unless everyone moves, so no one moves. Considering our paltry 15% or so EMR adoption rate, it seems like this is an apt description of EMR adoption as well. It does seem like many doctors are on the sidelines waiting for the first adopters to stick their proverbial heads out of the water and show all the other penguins the fish they’ve gotten."

Doctors are very conservative and hidebound and are reluctant to be the first to adopt new technology. However, by failing to do so , many of them are losing on a great new opportunity to improve their productivity and their patient care services. Lagging behind the competition can cause them to lose patients !

Why aren't more doctors willing to take the approach most entrepreneurs do ? Give it a try and see if it works ? What can software companies do which will encourage doctors to take this risk ? Offer free demos ? A free 30 day trial ? a money back option ?

I actually think this is an opportunity for clever doctors who want to stand out from the rest of the crowd !

Healthcare in India – From Consumer Perspective « Manish Rathi's Blog: "Healthcare in India as a ‘Product’ has grown leaps and bounds over the years in India. However, as a ‘Service’, my opinion is that Healthcare Services in India – not just from Providers side and but also to the same extent even from the Consumers side too – needs a serious relook (and in many scenarios – a reboot!). To a large extent Healthcare Services in India seems be centered around the Provider i.e. the Doctor. But as any successful consumer offering in the world would tell you – this service needs to be around the individual who needs it – the Patient. Please note that when I refer to a Service – I am not just referring to a scenario simply about how a patient gets treated by a doctor – but the complete process of how the consumer (patient in this case) goes through the process of figuring out what he/she suffers from; services best for them and their providers; and then getting the best and optimal service delivery."

I am an embryologist - one of the scientists who makes your embryos from your eggs and sperms in the IVF lab. In many clinics, the embryologists are tucked away in the IVF lab, which is why most infertile couples don’t have a clue as to what we do and how we do it. At Malpani Infertility Clinic, I routinely show our patients their embryos in the IVF lab. It’s much easier for them to understand what we do in the IVF Lab when they know the basic biology of sperm, eggs and embryos. Here’s a basic Reproductive Biology 101 course you should review before going in for IVF treatment."

How a D&C made me infertile ! : I tell all my patients that there is no such thing as minor surgery . This real-life story brings this message home dramatically ! Going through something like this not only scars the uterus - it also scars the psyche - and shakes up patient's confidence in their doctor. Here's a first person account from a friend, Rama."

Friday, October 23, 2009

Money For Investment: HEALTH INSURANCE PUSHING THE MEDICAL CARE COST UP ?: "Health insurance is supposed to be one of the first and foremost things that one needs to plan for while planning for his/her financial future. It aims to provide cover against any untoward medical expenditure that might come up in future. Health insurance is a very important and useful product,something that is usually recommended for one and all. But, these health covers also tend to have an unintended bad effect on the overall cost of medical care.With the increase in penetration of health cover among vast majority of Indians, the hospitals have started to benefit greatly from this. The overall medical cost is on the rise . Let us examine in detail, as to how health insurance may be pushing the overall cost of medical care up ,especially in private hospitals/nursing homes."

It always amazes me that even patients who are very unhappy with their doctor continue to stick with him ! I can understand why this would happen in public hospitals, where the poor patient has no choice. But why do private patients who pay their doctor good money to get good quality service put up with a doctor's bad behaviour and unprofessionalism ?

I feel there are may reasons.

For one, patients have already invested a lot of time, money and energy in getting treatment for their present doctor. This is a sunk cost which they need to recover and they are not very happy about writing it off.

Secondly, they need to console ( ? delude) themselves that they have made the right choice and are very reluctant to spend more energy trying to look for a better option.

Others just don't want to accept reality. Just like an abused wife, who feels she is trapped in a bad marriage, they feel they are powerless and are not able to get out of a bad doctor-patient relationship.

Some are scared of the doctor and don't want to upset him. The doctor "knows my case" and has all my medical records - how can I go anywhere else ? I'll have to start all over from scratch !

A few feel that the secret to getting better is to leave everything upto the doctor and just blindly follow his orders, no matter what ! They would never dream of using their own initiative or asking questions, leave alone walking out ! They feel that by deserting the doctor, they are being "bad patients" because they are being unfaithful or disloyal.

Some become "co-dependent" They put up with an abusive doctor, because they have become conditioned to a doctor's bad behaviour and feel this is " normal."

Others are worried that they may go from the frying pan into the fire - after all, there is no certainty that the new doctor will be any better !

Finally, some have never experienced how a good doctor takes care of his patients, so they are happy with the status quo because they do not know any better ! They feel that waiting times of over 3 hours are the norm and that all doctors make their patients wait endlessly. They put up with this because all the other patients do so as well - the Indian herd mentality at work. In fact, some perversely believe that the fact the doctor makes you wait so long means he is very busy, which just confirms what a good doctor he is !

It is true that it takes effort to get out of a bad doctor-patient relationship. My point is that it's well worth making the effort to do so. It's not that hard - and it's quite likely that your new doctor will do a much better job. After all, he is likely to be flattered that you selected him over your existing doctor, and will do his best to earn your trust !

I often treat patients who have failed an IVF cycle at another clinic. I always ask them what they liked about their earlier clinic; and what they didn't. We hope to learn from their experiences, so we can incorporate the positive features, and try to make sure we don't do things patients dislike.

One common complaint is - I never got to see my doctor after the first consultation ! There are too many assistants in the clinic, and every time, I see a new face and have to repeat my entire history all over again. There is no continuity, and if I ask questions, the commonest reply is - " I will have to check with the main doctor and find out the answer. " . This means most of my questions remain unanswered.

There is no bonding or empathy between the staff and me - and there is no one I can turn to in the clinic to hold my hand or provide a shoulder to cry on.

Thursday, October 22, 2009

Trust you are doing well and hope you had a great Diwali.I wanted to keep you posted on my health progress after my unfortunate miscarriage.My monthly cycles have resumed and appear to be quite normal. Post my miscarriage which happened on 24th August 09 I had my monthly cycle on 17th Sep 09 and next one on 14th Oct 09. The cycle seems to be very much regular and normal. As per your earliesr instructions I plan to undergo an ultrasound scan on the 10th day of my period this month i.e.24th Oct which is tomorrow and shall keep informed of the results. I believe this scan is to be done to check endometrium lining post the D&C process. Kindly let me know if I need to check anything else so that I may inform the sonologist accordingly.

In the meanwhile I wanted to inform you that I have been a regular visitor on your blog and website and would like to inform you that the blog posts and web info are simply amazing !!! In fact in one of your older blog spots I found a very interesting and informative article and wesbite link on miscarriage and trust me its was very useful for me. The information on the website helped me better face my trauma. I have regained my mental stability much faster even though my miscarriage was extremely traumatic for me. As advised by you I also attended an Art of Living course and have learnt some good meditation techniques. To sum up, I am gearing myself up for my next cycle with you and eagerly look forward to your support and guidance. I plan to visit you in Jan 2010.

Thanks a lot Doctor for all your help. May God bless you and your family and keep you healthy and happy always.......

Many Indians will agree that the Indian healthcare system needs an overhaul and quite a few young entrepreneurs are trying out clever new ideas to help patients get better medical care. A good example is the use of PHRs to help patients become empowered consumers. The major stumbling block they face is getting acceptance from doctors.

We all know that patients will do anything their doctors will tell them to do. However, if you suggest they try something using their own initiative , which their doctor has not explicitly recommended , most become passive observers and flatly refuse. They feel that medical science is best left upto their doctor . They don't know enough to try to do anything about it. My doctor knows best is a very comforting mantra ( even though it may be false !)

Doctors play a disproportionately important role in the healthcare system. They act as gatekeepers; experts; confidantes and advisors, and pretty much control the patient's purse, heart and mind. While this is all for the best if you find a good doctor, what happens if your doctor has a vested interest which is not aligned with yours ?

The tragedy is that it is bad doctors who are the biggest hindrance to fixing the healthcare system. The key question is - Who will bell the cat ? While everyone has a horror story to share about how bad the new generation of doctors is; and how commercial the profession has become, no one seems to be willing to do anything to address this. It seems that it's always "another doctor" who is bad or corrupt or who takes kickbacks - not yours ! Why do we take such an ostrich in the sand attitude ? If we refuse to acknowledge the problem ( no matter how bitter it is), how will we ever solve it ?

It is a few bad doctors who have ended up giving the entire medical profession a bad name. I am a practising doctor, and this hurts me. All doctors end up getting tarred with the same brush, making a bad situation even worse. The young doctors will often use the bad doctors as a role model . It's easy to salve your conscience by saying - I am just doing what my seniors do ! Justification becomes easy. Even the honest ones start giving in to temptation. If everyone thinks I take kickbacks, then I might as well start taking them anway !

My purpose is not to take a "holier than thou" attitude or to criticise. The medical profession is meant to regulate itself but we have failed to do so miserably. Turning a blind eye does not help - it just allows the pus to fester !

Talking to bad doctors is unlikely to help - they are not going to improve their ways. Good doctors don't need to be told - they are upright and ethical anyway. So how does one solve this situation . The only solution is to ensure that patients understand enough about their medical problem and treatment options, so that bad doctors cannot take them for a ride. This will help to weed out bad doctors - and will encourage the good ones, who will automatically start doing even better !

I am glad to see that things are now slowly changing ! UHC India has started a great new program called Diary 9 , which provides pregnant women with a comprehensive antenatal care package , in partnership with their doctor.

This is a great win-win solution. While most obstetricians provide good medical care, pregnant women have hundreds of other queries and doubts, which the doctor simply does not have the time ( or energy or desire ) to answer ! The Diary 9 program provides a comprehensive package of tests, scans and educational classes at a huge financial discount to women, so that they can take better care of themselves . Not only does this ensure that they get high quality medical care at an affordable cost, it also allows their obstetrician to focus on the medical aspects of their care.

At present, this is available only in select metropolises - but as time goes by, I am sure it will become more widely available !

Wednesday, October 21, 2009

"We are receiving treatment at SG FERTILITY CENTER in USA, our doctor is Dr FC who is very experienced, but I got to be honest with you, I learnt so much from your website last night, more than I have learnt from our doctor in 5 months."

Sometimes doctors and colleagues ask me why I spend so much time and energy on our website. It's words like these which keep me going. It's good to know that the effort we put in helps someone else in distress halfway around the world !

Indian doctors have a well-deserved global reputation for their clinical skills. They are usually technically proficient, hard working and take pride in their professional skills. They are very busy and manage a huge clinical work load efficiently and effectively.

However, the one thing they don't do well is share their knowledge.

This is sad. Even though they see lots of patients daily and have accumulated a lifetime's worth of clinical wisdom, they rarely write about their experiences.

Why don't they document their experiences so others can learn from them, rather than carry their lifetime of clinical wisdom to the grave ? After all, they are good doctors and should be happy to display their proficiency and expertise to others !Most have good English skills, because medicine is taught in English in India, so that communication in this international language should not be hard for them to master.

Let's look at some of the reasons why Indian doctors publish so much less than doctors in the US do.

In the past, doctors would write only to share information with other doctors. They would publish their experiences only in medical journals. Since most of these journals were published in the West, their editors would often turn down articles which came from developing countries because they were considered to be of poor quality or unreliable. This understandably put many Indian doctors off publishing all together ! After all, if the articles were going to get rejected, then why take the trouble of writing them ?

However, this is no longer true and there are many high quality Indian medical journals which will accept articles online, thus simplifying the submission of case reports and original scientific articles.

Most importantly, doctors no longer need to write only for doctors ! Today, thanks to the web, writing for patients has become even more important - after all, this is a much larger audience - don't forget that there are over 1000 patients for every doctor, and patients are thirsty for information !

The great thing about writing for the web is that this is a very democratic platform and there are no entry barriers. Everyone who wants to write can do so - you just have to want to do so ! Set up your own blog or website and start.

I feel Indian doctors don't write because of the hurdles they perceive - most of which are only mental blocks !

1. I am too busy taking care of patients. I just don't have the time to write. In fact, it's the busiest doctors who have the most insights to share and doing so should be high on their priority list.

2. Why should I bother ? What value does it add to my life ? My job is to take good care of my patients, and I do this well, thank you ! Sharing your wisdom with your patients and colleagues will help you to get even more patients, because you will be seen to be the expert in your community.

3. I am in private practise. Writing articles in medical journals in the job of lecturers and professors in medical colleges and teaching hospitals - not mine ! Every doctor has insights to share - and these are not the monopoly of teaching hospitals. Every patient has something to teach - you just have to be willing to learn !

4. I cannot write well. I know lots of interesting stuff, but don't know how to put in in words. Writing is a very hard skill to master, and I don't have the ability to master this. I could never write well in school, and am too old to learn now. Writing well can help you enhance the quality of your life ! It opens new worlds and keeps you mentally young. It's a valuable skill which is well worth learning !

5. I am just an ordinary doctor, who sees regular patients. I really don't have anything special or different to share ! How do you know until you try ? The fact that you are a doctor means you know more than your patients - and educating them is a laudable goal. If you don't do this, then who will ?

Part of the problem is that there is no pressure to publish , unlike in the West, where doctors consider it prestigious to see their name in print !

Indian doctors need to understand that the world has changed and they need to change with it ! Most of these "reasons" are just excuses and are actually easy problems to crack. Think of them as opportunities, rather than as hurdles - and once you discipline yourself and start writing regularly, this skill will allow you to shine and differentiate yourself from the rest of the crowd !

It's true that doctors are busy. However, you don't need to do the writing yourself. You can easily employ a secretary to transmute your thoughts into words. Don't think of this secretary as an expense. She can actually be an asset - and is an investment who will help you build your practise ! The secret for success for many leading doctors today is the fact that they have a superb secretary who organises their life for them. A good secretary is worth her weight in gold - trust me !

Doctors are often unsure about their editing skills or their ability to craft a well-honed sentence. Yes, this can be tricky, but you can always find an editor to polish your work. There are many "virtual assistants" available online, who can edit your articles and improve their readability !

I think we need to learn from US doctors. Even though they see far fewer patients, they publish far more. Their paper: patient ratio must be ten times that of Indian doctors ! Why do Indian doctors continue to hide their worth in the four walls of their clinic ?

I remember working with Dr Patrick Walsh at Johns Hopkins Hospital many years ago. He worked extremely hard - but not just at seeing patients ! He had 3 secretaries: one full-time secretary for the book he was editing, Campbell's Urology; one to organise his busy clinical practise; and one to help him with his hospital administration, since he was the Chairman of Urology at Johns Hopkins.

Skilled human labour is so much more inexpensive in India - why don't we leverage our strengths ? Why do we skimp on hiring good assistants ?

I feel it's time to stop making excuses and claim a leadership role - just like Indian IT companies have done !

If you don't want to write long articles, then just publish case reports. Videos and photos are very welcome as well ! And if you think of English as being a second language, then publish in your own mother tongue - the opportunities are even larger here, because there is much less competition !

As a patient, you need to trust your doctor. However , how do you find a doctor whom you can trust. There is no easy answer to this complex problem. Most patients will rely on their family doctor to refer them to a specialist - and will then blindly obey whatever this doctor advises. Others will choose a doctor by his reputation, and then faithfully follow his instructions. When the outcome is good ( as it usually is !), this method works well. However, if something goes wrong, patients become bitter and curse the doctor. They feel he took undue advantage of their blind trust in him; and seek revenge.

I tell patients they they must find a doctor they can trust - but the doctor needs to earn this trust. You cannot just give it away ! Listen to the doctor's advise, and then check on the web whether his advise makes sense or not ! If it does , then your confidence in the doctor increases even more ! " Trust, then verify " is a very sensible approach.

Two of the commonest complaints patients have about their doctors are:1. He makes me wait for ever and ever2. He never explains what is wrong with me and what he is doing and why

I think these complaints are just symptomatic of the fact that some doctors just don't respect their patients. While these doctors can be great at providing VIP care to VIPs, unfortunately they fail to extend this courtesy to all their patients.

It's true that the doctor-patient relationship is one of unequals and some doctors like being on the pedestal. After all, the doctor is the one who is the expert; he is the one who has all the information; and he is fully clothed !

You, on the other hand , are sick and scared; confused and unsure of what this illness means to your health and wellbeing. You find it difficult to make sense of all the medical jargon he throws at you; and are scared to ask questions, because he is so busy and there are so many other patients waiting. Even worse, you are half-naked in a flimsy gown which is designed to take away your dignity !

Because doctors are so busy and have so many patients to see, they are often likely to be curt and abrupt; and because their patients do not understand the technical minutiae of their superspecialty, they are forced to "dumb down" and talk to their patients in simple terms they can understand. This is likely to give them a superiority complex; and because most doctors learn medicine in busy charitable hospitals, where patients are poor and completely cowed down and unable to question their authority, some doctors never lose their arrogance. The only consolation is they treat everyone with disrespect - their staff , assistants and other doctors, not just you !

After all, if all your patients look upto you as their saviour, this is likely to go to your head - who are you to argue with their high opinion of you ? Doctors need to remember that we are all ignorant - it's just that the areas and depth of our ignorance can differ !

Patients need to be respected - not just the rich and powerful, because they can easily take care of themselves. Good doctors are especially careful with the poor and the illiterate - they need his protection and courtesy far more !

Tuesday, October 20, 2009

For many infertile patients, the biggest frustration they encounter is the answer they often receive from the infertility expert - We don't know !

This is true for some of the commonest problems in reproductive medicine, such as: unexplained infertility; recurrent pregnancy loss ; and failed implantation after IVF.

Does this mean that infertility specialists are ignorant or badly informed ? Of course not ! It just means that medicine is a complex science, and it's often not possible to find out what the underlying problem is.

The tragedy is not that we don't know. The tragedy is that when patients are told we don't know, they get paralysed into inactivity ! Their fear is that if the doctor does not know what the problem is , how will he be able to fix it ?

The good news is that you don't often have to understand a problem in order to solve it - you can often bypass it ! Often, it's cheaper and easier to do so, rather than waste time on a diagnostic quest which is often futile !

Remember that doctors are used to making decisions when confronted with uncertainty, so there is no need for you to lose heart ! The important thing is to acknowledge the limits of medical science, and then move on.

While doctors love earning money, they hate keeping accounts ; and interactions with accountants are high on a doctor’s “hate to do” list. A doctor who owns his own clinic has the thankless job of having to maintain accounts. Most doctors have varied methods of maintaining financial records, but all of them get the jitters when it comes to filing their income tax returns. So much paper work and so much time wasted ! Isn’t there a simpler way of managing your accounts? Well technology and software run banks, so why not your clinic as well ?

Plus91 has integrated its Practice Management EMR solution with a simple and effective accounts module which manages earnings, general payments, HR payments and referral payments . Here’s how Plus91’s billing module helps you keep your accounts.My patients usually come in one after the other. It is difficult to keep track of how many came in and also their billing status. Making the receipts is a very cumbersome process for my secretary. What do I do?

The accounts module in our software packages is integrated with the visit management, and allows you to automatically create bills and receipts during the patient visit within seconds. It accepts inputs from the EMR and auto generates the bill with rates you have entered earlier, so that no time is wasted in billing. This means you no longer have to go through multiple screens just to prepare a bill for a patient. Plus91 allows you to generate the bill during the patient visit within seconds. You can also keep track of the bill amount and payment status in a single window , thus making life simpler for you and your secretary.

A lot of time my patients pay their bills piecemeal This means that their payments for earlier visits is often pending when they come for a followup visit. How can I collect the pending payments more efficiently ? It is irritating to go back to the old account books and make a list of payment pending entries. I need something which is more efficient !

Yes, making lists of pending payments can be quite cumbersome, which means a lot of time the patients default on their payments and you lose this income. Plus91 remembers which bills have been only part-paid. This means creating an unpaid bills report ( accounts receiveable) is just a simple click away. When the patient pays the remainder due, you just need to update his billing record, and his name is automatically cleared from the pending list !

My CA ( chartered accountant) insists he wants all income and expenditure neatly filed under various heads and given to him in an Excel sheet. It is tough enough to put everything down on paper – putting everything on Excel is twice the work ! Can software help me overcome this problem?

Many doctors cancel their appointments and stop seeing patients for 2-3 days every year when they are stuck at their CAs. The reason they waste so much time there is simply books are a disorganized mess of registers, papers and bills. Going electronic allows our intelligent software to do the work for you , so you can earn more money seeing more patients ! Once you start using Plus91, the amount of time you will save in interacting with your accountant will more than make up for the cost of the package in the first year itself ! Plus91’s accounts package allows you to create ledgers ; profit and loss statements; and allows you to export all this into formatted excel sheets, making your life much easier. Soon, you will be able to export this into Tally , making sure your CA votes you as being his favourite client !

How do I make sure my staff hands over my daily collections to me ? How can I monitor them more closely to make sure they aren’t siphoning off my heard earned money ?

Even though doctors are daily wage earners, they are surprisingly naive about handling money. A lot of their income is in cash; and because they are so busy, they often have to trust a clerk or secretary to collect their fees. This makes them easy targets for embezzlement; and the embezzling is usually done by their most trusted staff member ! What do you do if he “forgets” to enter a patient in your register ? Or if he fails to prepare a bill and pockets your money ? With Plus91, each patient you see is present in the system , so it is easy to keep track of how many you have seen. Since creating the bill in part of the clinic process flow , this allows you to track the status of each patient with respect to their payments ! I don’t want all my staff to know how much I earn ? If I keep all my financial transactions on Plus91, then every one will know what my income is !

Plus91 allows you to set passwords, so that privileges are set for each user. This ensures that your staff has access only to what information you want them to see. You can keep whichever part of the record you want confidential and do not need to share it with them if you do not want to .

Many of patients have health insurance and I need to get the TPAs to pay my bills. They want me to format my bill according to various heads – and these rules vary from TPA to TPA ! If I want prompt payment from the insurance company, I need to do this. Will Plus91 help me?

As health insurance takes center stage in India, TPAs are insisting that the bills you submit to them for reimbursement be created in a certain format. Because they control the flow of money, they can pretty much demand this, and doctors will have to comply. Plus91’s claims package has integrated these formats into its solution. By choosing the correct option, you just need to fill in the appropriate fields and you will be able to complete the formalities in a jiffy. What’s more the software allows you to re-format the bills as needed, allowing a lot of flexibility.

I need my inventory and other payments to be managed directly, without having to make entries twice. Having different programs to do this reduces my efficiency !

When you purchase medical equipment ( ranging from a chair to office stationary), you have to create a voucher for the same; make a debit entry in your ledger and also make an entry in your inventory register. That’s two steps too many for a simple purchase ! Plus91 allows you to do all this automatically by filling one quick form. Just add your voucher and let the software do the rest. I have to track doctors who refer patients to me . I need to be on top of this so that I do not lose out on patients. Can you help me with this?

Referrals are an integral part of the Indian Healthcare system. There’s no need to waste time doing these calculations if you use Plus91 ! Plus91’s referral systems keeps tracks of all the patients referred to you by various doctors. You can generate month end reports in excel and send them to your referring doctors.

My billing needs to be very flexible, as I often have to give a discount to poor patients. How can you help me to manage this ?

Plus91’s billing module allows you to be very flexible . You can add a discount or a tax as needed; or charge different rates for each of the procedures you perform.

The only things most doctors hate more than keeping accounts is paying taxes. This will be the subject of the next post.

My father has written volumes on this topic- but I didn't give the question much importance until I underwent elective surgery.I underwent a relatively simple and common procedure, but I was still hyper about my doctor.

I went to a really famous doctor for my first consult. He had people flying in from all over the world to see him, and had been fecilitated by the government for his services. He had expensive, brand new equipment- but I refused to see him again.He spent absolutely no time on me, barely glanced at me reports, waved away all my doubts, and tried to get me to do the procedure as soon as possible. He acted like a hard selling salesman- and I didn't want to be a customer, I wanted to feel like my doctor actually cared about my health.

The other doctor I went to was a complete contrast. He did all the tests himself, set aside an hour to answer my questions, had all his protocols in place, gave his patients sheets explaining what to do before and after the surgery, and what to expect during the procedure. He clearly stated that I should not go through with it unless I was comfortable with it, and wanted it to be my decision.

I know that in the end, they're both in it for the money- but their approach makes such a difference. The second doctor was located in a far less convenient location- but I was willing to go across town for him, and will recommend him to people, simply because he spent time on me. He also had a great website, that addressed all my fears and questions- which again was a big plus point in his favor.

Monday, October 19, 2009

Search Engine Optimization for Doctors -: "'But do local patients even search online for my profession or specialty?'While in the early days of the Internet doctors typically overestimated the number of searchers online, today we notice that most doctors underestimate the number of potential patients they could reach through their Web searches. Your highest income, most educated patients do, in fact, search for you on the Web.

Moreover, the higher risk, serious, scary and/or expensive treatments are particularly likely to be searched. Thus, patients considering surgery are more likely to search online than those who are considering upgrading the style of their eyeglasses.

Finally, patients often use the web as a way of doing due diligence. So even if their family doctor has referred referred them to you, they still may want to 'check you out' before coming in for an appointment. And even if they don't their sons and relatives will do so !

I often see patients who have received poor quality medical care. Many of them are very bitter about this and often blame the doctor who provided the suboptimal care. While it is true that the doctor is responsible for ensuring he provides good quality care, I feel that blaming the doctor if he fails to do so does not help anyone. In fact, it just creates a lot of unhappiness and resentment in the patient's mind, which blocks healing even further.

I tell patients that the best approach is to forgive the doctor and to move on. It;s best to be charitable - after all, every doctor tries to do their best. It's easy to criticise with the wisdom of 20/20 hindsight, but this is unfair on the doctor , as outcomes are often uncertain at the time treatment is provided. Never attribute to malice what is often a result of stupidity ! However, it is important that you learn a lesson from this. The lesson is simple - your health is too important to leave upto the doctor ! You must learn enough about your own problem so you can make sure the doctor is providing you with the right treatment.

If you learn to take responsibility for your medical care , you can improve the odds of having a good outcome the next time around. And while you cannot ever ensure a good outcome, at least you can improve the odds in your favour of getting better medical care. Everyone is allowed to make a mistake once. Smart people don't make this twice !

Most Indian hospital websites have poor quality content. The website for Apollo Hospitals is a good example. Even though it claims to have won a lot of awards, the informational content which is provides for patients about their body and its diseases is very poor. They just have one section called Health Guide, which provides very limited and patchy information.Most of the website is all about Apollo, rather than about serving the information needs of the visitor - which is Marketing Sin # 1.

Sadly, most other hospital websites are even worse ! The Fortis website just has a few health tips for patients - that's all !

What a sharp contrast from US hospitals such as Mayo Clinic. The Mayo Clinic website is packed with information for patients. This information is comprehensive, encyclopedic and easy to understand, so that users are likely to keep on going back to the website. What a great way of branding, marketing and creating value by providing what the patient wants !

Is it that the marketing departments of Indian hospitals don't realise that their patients are going online to educate themselves ? If they provide this information, they will be able to create loyal patients very quickly and inexpensively ! Or is it that hospitals don't respect their patients need for information ? Why do Indian hospitals force their patients to look elsewhere for this ? Why don't they provide it themselves ?

Sunday, October 18, 2009

How your GYN can be dangerous if you are infertile: "Most infertile couples go to a gynecologist for their medical treatment. While gynecologists are usually a good first choice for treating infertility, they do not have any specialty training in this field where the technology is progressing by leaps and bounds, as a result of which they can actually harm your fertility. Here are some of the common mistakes which gynecologists make when treating infertile couples."

Sir .i show your mail sir. my IVF failure 3 eggs removeing .then 2 embryo put insaid i dont no dr.which tiyph eggs .i have no any pappers .he is toll me all o.k 2 week take rest ofter come check blood like that i take rest .ofter i go blood test he is telling negative .i cont i sak what hapen dr. dr say your oven insaid problam try again .becouse of i have no tube 3 times befor come tube pregnancy like that my both tube remove befor now my age 35. my blood test all o.k not any other problam but this come negative my money is all going this i will doit Bahrain country .please sir tel me your i dea nest too maths ofter want imake again any problam com .becouse now my husbent not nice with me .who mistage this one what hapen like this come please sent me replay i want go one more .

It is obvious that English is not her first language and she has been very brave in framing this email and reaching out for help.

So what makes this email so tragic ? Let me re-write her email in English - and then try answering her questions.

Dear Sir, I would like you to see my email. I have just had an IVF failure. The doctor removed 3 eggs and transferred 2 embryos. I don't know what type of eggs. I don't have any papers. My doctor told me everything was OK. He advised me to take rest for 2 weeks and come for a blood test. I did that but the test was negative. I don't know what happened. The doctor said you have a problem inside, which is why the cycle failed. He suggested I try again. I have no tubes because both my tubes have been removed because of earlier tubal pregnancies. I am now 35. My blood tests are fine and I don't have any other problem. All my money has gone into his treatment. I did this in Bahrain. Please tell me what your advise is. What should I do next ? Will there by any problem if I try again ? My husband is not nice with me anymore. What mistake happened this time ? Please send me a reply - I want to try once more.

It's hard to provide her with an intelligent explanation because there is no medical documentation of her past cycle. However, this email highlights that IVF patients feel abandoned after a failed cycle. They are often left high and dry , without even the courtesy of an explanation.

Doctors often underestimate the patient's ability to understand medical treatment. The treatment may be technically complex, but just because they cannot read or write well does not mean they don't have brains which can understand - or hearts which can break !

For all practical purposes, she will have to change her clinic and start all over again with a new ( and hopefully better ) doctor. The tragedy is that details of the failed IVF cycle could have provided the new doctor with useful information which he could have used to modify the treatment protocol for the next attempt. This information is now simply not available, so the patient is now back to Square One.

However, this bad experience will hopefully make her a more careful patient the next time around - one who asks questions and gets answers !

Medical tourism is becoming increasingly popular . Many infertile couples come to India for their IVF treatment because they are looking for value for money and refuse to pay the astronomical fees IVF clinics in the US charge.

One major bottleneck in the past was the fact that their local US doctors would often refuse to prescribe the basic tests and medications they needed for their IVF treatment. Because of this, many patients were locked into the US medical system, and could not explore alternative options.

The good news is that now there are alternative options available to US patients, so they are no longer completely dependent upon the cooperation of their local MD. This gives them a lot of freedom !

Here are examples of 3 websites which allow me to help patients living in the USA, even before they come to me.

Most patients will need some basic medical tests done before we can start their IVF treatment.

These include blood tests to check their hormone levels, such as FSH, LH, prolactin and TSH. These can now be ordered online at www.mymedlabs.com !

Also, they need imaging studies, such as a vaginal ultrasound scan. They can now find a radiologist to do this scan for them at www.remakehealth.com !

Will this encourage overtesting or self-testing. The simple answer is - No. Patients still need a doctor's prescription to do these tests and buy these medicines. The only difference is that they are no longer forced to use their local doctor's services - they can find another doctor ( often better and less expensive) in India !

This means that patients are now empowered to manage their own treatment ( with some help from me !) and are no longer limited by the expensive options their local medical facility offers ! Even better, because these websites cut out the middleman, patients end up saving a lot of money by using these services, which are priced very competitively and transparently.

Saturday, October 17, 2009

One of the commonest questions patients ask me is - Doctor, how can I improve my sperm count ?

Even men with normal sperm counts want a medicine to increase their sperm count ! They feel that the more the sperm they have , the higher their chances of their achieving a pregnancy. After all, more is better ! This seems quite logical in a society which is obsessed with numbers, even though it is not true.

The sad truth is that there really is no way of improving a low sperm count. Unfortunately, patients rarely want to hear the truth, which is why they end up wasting a lot of time, money and energy in trying to do so. The tragedy is compounded by the fact that a lot of doctors ( and quacks) and happy to take advantage the infertile man's desperation.

Why are there still so many myths and misconceptions regarding medications to improve a low sperm count, if nothing works ?

This is because most men expect that their doctor will prescribe a medicine which will help them to increase their sperm count, and fix their problem. After all, they expect that if medical technology has become so advanced, then there must be some treatment available to correct such a common problem !

The problem with the medical treatment of a low sperm count is that for most people it simply doesn't work. After all, just as an example, if the reason for a low sperm count is a microdeletion on the Y-chromosome, then how can medication help to treat a genetic problem ? The very fact that there are so many ways of "treating" a low sperm count itself suggests that there is no effective method available. This is the sad state of affairs today and much needs to be learnt about the causes of poor production of sperm before we can find effective methods of treating it.

However, patients want treatment, so there is pressure on the doctor to prescribe, even if he knows the therapy may not be helpful . Since most people still believe there is a "pill for every ill", they do not want to hear the truth that there is really no effective treatment available today for increasing the sperm count.

Since most doctors know this, they are pressurised into prescribing medicines for these patients, because they do not want the patient to be unhappy with them. They are worried that if they do not fulfill the patient’s expectation of a prescription, the patient will desert them, and go elsewhere, which is why they often do not tell the patient the complete truth. The doctor also remembers the occasional anecdotal successes (who come back for followup , while the others desert the doctor and are lost to followup) is why patients with low sperm counts are put on every treatment imaginable - with little rational basis - clomiphene, HMG and HCG injections ( using the rationale that what's good for the goose must be good for the gander !) proxeed, testosterone,Vitamin E, Vitamin C, anti-oxidants, high-protein diets, hoemeopathic pills , ayurvedic churans and even varicocele surgery. However, the very fact that there are hundreds of medicines itself proves that there is no medicine which works ! ( After all, if one medicine worked, then all doctors would prescribe this, so there would be no need for so many different medicines !)

Many doctors justify their prescriptions by saying - " Anyway it can't hurt - and in any case, what else can we do? " However, this attitude can be positively harmful. It wastes time, during which the wife gets older, and her fertility potential decreases. Patients are unhappy when there is no improvement in the sperm count and lose confidence in doctors. It also stops the patient from exploring effective modes of alternative therapy - such as IVF and ICSI. Today , empiric therapy should be criticised unless it is used as a short term therapeutic trial with a defined end-point.

A word of warning. Medical treatment for male infertility has a low success rate and has unpleasant side effects, so don't take it unless your doctor explains his rationale. The treatment is best considered "experimental" and can be tried as a therapeutic trial. Make sure, however, that semen is examined for improvement after three months and then decide whether you want to press on regardless.

So what should you do if you have a low sperm count ? First, don't panic ! Sperm counts tend to fluctuate quite a bit, so don't jump to conclusions on just one report. Doctors know thatcounts do vary over time for reasons which are not clear . This means that just because your counts increase after you took a particular medicine does not mean that this medicine caused the count to improve !

Some of the advise is very basic. You need to stop smoking and stop drinking alcohol; and re-test your sperm count after 2-3 months, from a reliable laboratory.

If the count is persistently low, and you have failed to achieve a pregnancy in over one year, then you should consider going in for ICSI treatment. While this will not improve your sperm count, it is the one option which gives you the highest chance of having a baby !

Online health care shopping made simple and affordable.: " RemakeHealth’s online health care shopping site gives you a new way save money on your medical expenses. We help you answer questions such as “How much does an MRI scan cost?” and then let you conveniently, safely buy your doctor ordered Radiology test with your credit card. Our site features over 1500 Radiology centers in California, Florida New York, Arizona, New Jersey, Illinois, Indiana, Iowa, Pennsylvania, Texas and more featuring nearly every outpatient Radiology test."

This is a brilliant idea.

Medical imaging tests cost an arm and a leg - and most patients have no idea how much each test costs, because their insurance pays for this.

This clever site allows uninsured patients to shop around for the best value - and this kind of transparency will help patients to get the best prices for their tests.

It's a win-win situation, because it also allows Imaging service providers to get direct referrals !

2 weeks ago, I spent the better part of a day travelling back to Pune from Bhandara ( near Nagpur ) after having completed an installation of Ultrasite in a diagnostic center. As anyone who has travelled on Indian roads can testify, this was a long and arduous trip. There has to be a better way of installing software - and we think the internet now provides a much better solution ! For example, in the last week , we completed two installations at Varanasi and Solan without even visiting the locations.

However, there is a process involved, which we have now mastered. This involves the following steps: software delivery; training: exchanging information for providing troubleshooting and support; and accepting online payment.

It is vital to have a good website which educates doctors about your products and services. It's then important to use a program which allows remote management. Teamviewer and Logmein are effective - and are free ! Finally, your process flow for installation should be simple and easy to perform. At Plus91 , we take only about 10 minutes to complete an installation through the net !

What have we learned so far ? If the doctor's net connection isn't fast , it makes sense to courier him a CD with the executables ; or ask him to download it from secure temporary links when he is free . Our files are not big, but then again the Internet speeds in India aren't brilliant everywhere either. Next , it is vital to be able to provide training remotely. We have many online training tools on our website, including a comprehensive Help manual ; video help files and screencasts. We still get the occasional call asking for help, but these have been few and far between .

Email and chat are the best ways to exchange information and track any changes required. A formal ticketing system on the website is also a good idea to help improve customer satisfaction .

Finally, payment by NEFT ( National Electronic Funds Transfer) is a simple process with each branch of each bank being seamlessly connected. Doctors usually never have a problem with this part , though they do argue about the pricing :).

Over all , our company with its lean and mean sales force has been able to serve and manage sales and support for doctors from all over the country thanks to this method. We now have quite a few doctors in remote parts of India using Plus91 software , many of whom I have never even met - and perhaps never will !

Menstrual flow, menstrual periods and infertility: " All women know that their menstrual cycles, ovulation, and fertility are inter- connected. Unfortunately, they are very confused as to how and why, which is why myths and misconceptions about menstrual periods and infertility are legion."

Are you worried that your menstrual flow is affecting your fertility ? This article explains the relationship between scanty menses; heavy periods; and fertility.

I'd like to see us following the money a little more assiduously. There are remarkably few investigative journalists in medicine, and there's so much to cover. I'd also like to see more skepticism. Where were the really critical journalists when researchers announced recently that CT-scanning for lung cancer could save lives? That research was full of holes, and any reporter who had the sense to go to one of several experts in screening epidemiology would have learned there was more to the story than met the eye."

Unfortunately, health reporting in India leaves a lot to be desired. This is especially true, now that the lines between advertising and editorial have become so blurred !

Medical tourism is occasionally associated with unsavoury practices and practitioners. On the whole though, it is unfairly maligned. The hostility directed against it is motivated by narrow interests, short sightedness, scare-mongering and ignorance."

One of the excuses many doctors give for not talking to their patients is their concern that the patient will not understand all the technical minutiae. Their approach is - It took me 10 years to master medicine. How can a poor patient possibly understand all the subtleties and complexities in 10 minutes ! I am a good doctor and will decide what's best for the patient, based on my vast experience and great expertise. What's the point in confusing the patient and burdening her with knowledge will may go above her head ? Isn't it better than I take control of her medical course - after all, that's what she is paying me for ! This way, she can focus her energies on getting better, while I work on her medical treatment.

While this paternalistic approach is still surprisingly common in India even today, the fact remains that this is a broken model. Patients want to be treated with respect - and while they don't want to become doctors themselves, they want to make decisions about their own bodies !

Using the pretext that patients will not understand it just a copout in my opinion. Nothing is so complex that it cannot be explained - and if the doctor cannot do so, it just means that he is a poor communicator and needs to improve his skills. This is true, even when the patient is illiterate as well. A good doctor will spend time and energy developing models, tools and stories which he can use to teach his patient.

And if you think you are too busy to do so, you should strongly consider employing a doctor or nurse to educate your patients for you. If you don't, you'll find a lot of them will walk out of your clinic to the doctor next door !

In the agreement worth about Rs 90 crore, Perot Systems will provide full infrastructure management capabilities, data hosting, infrastructure support, project management support, help desk support and the implementation and clinical adoption of an electronic health records system. The integrated hospital information system and electronic records will allow access to complete patient information across MHC.

These advances are expected to enable MHC to improve the quality of care and patient healthcare delivery through better record accessibility, computerised physician order entry and care planning."

The Indian healthcare industry is maturing and is using IT to improve healthcare. This is great news.I am sure this will have a trickle down effect and other hospitals, clinics and doctors will soon follow suit, as they see the many benefits which EMRs offer to patients !

Most patients naively expect that the success rate in an IVF cycle is 100%. After all, if the doctor is actually making the embryo in the laboratory, then isn't it a certainty that the embryo will become a baby once it's put back into the uterus ? After all, it's then just a question of the embryo sticking to the uterus, and if my uterus is normal, then I am sure to get pregnant !

I wish life was that simple !

Unfortunately, embryo implantation is a complex biochemical process which involves the interplay of signals between the embryo and the uterine lining. We don't understand too much about this process and cannot control it at all.

When an IVF cycle fails, we glibly tell the patient that the reason is - Your embryos failed to implant. Actually, this is just a way of covering up our ignorance. Embryo implantation is still a "black box" into which we have very limited insight. When you think about it, what we are doing is transferring a microscopic ball of cells into the uterus. We really have no way of tracking its fate or figuring out why it did not "stick", once we have done so.

When doctors tell patients that their problem is " failed embryo implantation", patients are quite hopeful. Now that the doctor "knows" what the problem is, he will be able to fix it. Actually, Failed Implantation is a "waste paper basket" diagnosis. While it's a convenient short-hard term when discussing IVF outcomes with patients, in reality it tells us very little about what went wrong; why it went wrong: or what we can do about it. However, labelling it as failed implantation gives patients the impression that we know what's happening and are in control of the situation !

The problem is that patients start feeling that their body is " rejecting" the embryo; or that they did something wrong, as a result of which the embryo " fell out." It's just that human reproduction is not a very efficient enterprise, and this is true, whether embryos are being made in the bedroom or in the IVF lab !

1. I am not IT savvy and do not want to invest in buying and learning new stuff. This is a good opportunity to make the doctor realize how Plus91's clever technology can help to improve their life. Real-life stories which show how other doctors have used Plus91 products successfully can help them to overcome their skepticism.

2. I am too old or old fashioned to invest in a software program now . This is probably the toughest lot to convince, because they are contented with that they have and do not feel the need to improve or upgrade. Showing them that Plus91 is easy to use and does not involve a lot of computer skills or typing can help.

3. I already have a software program and I quite like it. This can be a tough group to convince , especially if they are in love with their old software. Ask them to show you what they like about their existing product. This can actually be a great learning experience for you, and by incorporating these features, we can improve Plus91 even more ! If Plus91 is better, then we emphasise these benefits !

4. I bought a software program but I wasted time and money, because it was of no use.This is the “burnt child dreads the fire “ syndrome. We spend a lot of time and energy explaining why Plus91 is better and how we provide excellent after sales support. It’s worth spending this time, because these doctors are the “early adopters “ – and are likely to become evangelists if your product does a good job !

5. I am not too keen on introducing a program in my practise as I do not have the time to use it - I am too busy taking care of patients and cannot waste time on a computer, entering data . Plus91 is easy to install; and this installation will not disrupts the clinic’s smooth working. In fact, a Plus91 can actually help the doctor to save time and to see more patients by improving his efficiency !

6. I do not think your software meets my requirements. I want more/less/something different . The beauty about Plus91 products is that it’s very easy for us to modify the templates. We can customise and adapt these to suit each doctor’s convenience – and we can even do this online ! Clever technology allows us to adapt the program to the doctor, rather than forcing the doctor to adapt his habits to suit our program !

7. I do not want to meet you, as I am not interested . Some doctors have already made up their mind and are likely to be the dinosaurs who get left behind, because they cannot adapt and evolve with changing times. If they tell us why they are not interested, we can try to explain to them why it’s worth their while to at least allow us to demonstrate our product to them, rather than reject it out of hand.

8. I prefer the cheaper or free option I am getting from my relative/pharma company/local provider. Remind them that you get what you pay for – and if you pay peanuts, you are likely to get shoddy stuff, which works poorly, and is likely to be more of a liability, rather than an asset. It’s not a good idea to allow them to bargain or to offer a discount. You need to explain that the product is an investment, not an expense and will pay for itself in improved productivity very quickly. If the doctor is stuck on the price, it’s better to walk away rather than to haggle, because our products are inexpensive and very well designed. Doctors have to agree to pay for quality and service – nothing in life is free !

9. I cannot type. Yes, this is a major hurdle for doctors who cannot type and are uncomfortable with using the keyboard. Fortunately, the introduction of tablet PCs with handwriting recognition and voice recognition will make it much easier for them to use an EMR.

10. I do not have a PC . This has become a very uncommon excuse in this day and age. PCs have become very inexpensive and we can always get them a good deal in partnership with a vendor. Once we teach them how a PC can improve their life, they are always be grateful to us !

Ovarian cysts are very common and are frequently found in infertile women. However, there are of many types and cause considerable confusion - for both patients and doctors !

First, you need to understand that even a normal ovary will always have cysts !The commonest type of ovarian cyst is just a normal ovarian follicle - the little fluid filled cavity in which the eggs grow. Usually, only one follicle develops per month. This follicular growth can be monitored by vaginal ultrasound. The follicle appears as a circular fluid-filled bubble on the screen, and can be seen when it is about 7 to 8 mm in size. It grows at about 1 to 2 mm per day, and is ready for ovulation when it measures 18 to 25 millimeters in diameter. Following ovulation, the follicle usually disappears from the scan picture completely and this is the best evidence of ovulation.

When a follicle gets to be bigger than about two centimeters or so, doctors call it a cyst. Please remember that it's often just a name game - a question of semantics. Thus, this kind of cyst is just an enlarged follicle ! Since it arises during normal ovarian function, it is called a "functional cyst" ( though the term dysfunctional might be better !) and nothing needs be done other than wait it out because it will usually dissolve on its own.

If the cyst is large, many doctors will use birth control pills to cause it to regress. Because pills suppress ovulation , they will usually suppress the cysts that develop as a result of this.

Can the cyst be more sinister ? Could it be an ovarian cancer, for example ? This can be a possibility, but the good news is that the chances are very low. For most women, the vast majority of cysts are benign. However, the fear of cancer causes some gynecologists to become trigger happy and perform a laparoscopy to find out what's going on and to remove it. Unfortunately, this unnecessary surgery often reduces the patient's fertility by reducing her ovarian reserve, since normal ovarian tissue is also sacrificed during the surgery.

When should you worry about the cyst being a serious problem ? Large cysts ( more than 5 cm in size) need to be monitored more carefully; especially if the ultrasound scan shows that there is solid tissue within the cyst ( the technical word for this kind of cyst is a complex cyst). Some doctors will use blood tests called tumour markers such as CA-125, to help find out the type of the cyst. These levels are increased in patients with some kinds of ovarian cancer, but unfortunately these tests are rarely helpful, because elevated levels can be found in a wide variety of other conditions as well.

For most simple ovarian cysts, watchful waiting is the best approach.

In the next post, I'll discuss some diseases which cause cysts, such as endometriosis and PCOD.

Wednesday, October 14, 2009

I saw a patient today who was in tears. She wanted a baby, but because she was obese, her doctor refused to treat her infertility until she lost weight. She already had low self-esteem because of her infertility - and this just made a bad situation even worse.

She said - Doctor, I have tried so hard to lose weight. I have joined a gym and spent a fortune on diet books, but nothing seems to help. I don't like being fat, but no one is able to help me lose weight. Should I be punished for something I cannot control ? My biological clock is ticking away - and I feel it's very unfair to refuse to treat me just because I am obese. It's not that I am lacking will-power - it's just that I cannot lose weight, no matter what I do. How does blaming me for my obesity help ? If I was diabetic, would you refuse to treat me ? Isn't obesity a medical problem too ? Life is so unfair ! My sister is even fatter than I am - and she has 2 kids . I am sure I can get pregnant with the right treatment - and I will make a good mom, so can you please help me doctor ?

It is true that being overweight reduces fertility and that reducing weight helps to improve fertility. However, blaming the victim does not help. Doctors need to take a constructive approach and try to help them, rather than refuse to treat them point-blank. It's a good idea to refer them to a dietitian for help - but we all know that the weight-loss industry has a terrible track record and that we really are not very good at helping our obese patients to lose weight.

This is actually our failing rather than the patients, and I don't think it's fair to reject them.

In any case, making a baby just needs 4 things - eggs, sperm , uterus and tubes. Where do calories come into the picture ?

I agreed to do her infertility workup , so that we could find out what medical problems were reducing her fertility and try to fix them. She was extremely grateful because she could finally see light at the end of the tunnel !

There is no such thing as a "minor operation"- and this real-life story brings this message home dramatically ! Going through something like this not only scars the uterus - it also scars the psyche - and shakes up patient's confidence in their doctor. Here's a first person account from a friend, Rama.------------------------------------------------------------------------------------------

There are some things doctors tell you and then there are a whole lot of things they don't.

Most folk would do the smart thing by reading up and being prepared. I had ALWAYS put myself in this category - after all, I have access to the net, I am a voracious reader, and I hate being helpless. In other words, I was full of my own cleverness. Unfortunately I wasn't prepared for something as traumatic as a miscarriage - something that took me by absolute surprise, turning my world upside down in a heartbeat - and quite literally so.

Most women are still unclear about the difference between follicles and eggs.

The egg develops within a follicle in the ovary. This follicle ( derived from the Latin word for nest) is a thin-walled structure containing fluid, with the egg attached to the wall. Usually, only one follicle develops per month. This follicular growth can be monitored by vaginal ultrasound scanning.

The follicle appears as a black fluid-filled bubble on the screen, and can be seen when it is about 7 to 8 mm in size. It grows at about 1 to 2 mm per day, and is ready for ovulation when it measures 18 to 25 millimeters in diameter. Following ovulation, the follicle usually disappears from the scan picture completely and this is the best evidence of ovulation.

The egg, on the other hand, is a microscopic structure, which cannot be seen on scanning. For most women, it is true that the follicle does contain an egg. However, this is not always true.

Thus, just because you have follicles in the ovary does not always mean your eggs are of good enough quality to give you a baby. In order to get more information on your egg quality, the doctor will need to perform biochemical tests. These are of two kinds.

The first kind of blood tests check your ovarian quality - what is called ovarian reserve . These include tests such as the level of FSH, AMH and estradiol. These give the doctor an idea about how many eggs are left in your ovary. The correlation between the quality of eggs in the ovary and their quality is usually good. This means that if your ovarian reserve is poor ( you have few eggs left) , this also usually indicates that the quality of your eggs is likely to be poor.

The second kind of test allows the doctor to judge when the follicle is mature and gives an rough measure of the quality of the egg in an individual cycle. The follicle is lined by granulosa cells which produce the hormone estrogen. As the follicle matures, it produces increasing quantities of estrogen. Rising levels suggest that the granulosa cells are of good quality , thus indirectly allowing the doctor to conclude that the egg is of good quality. A mature follicle produces about 200 - 300 pg/ml of estrogen.

However, a direct assessment of the quality of the egg ( the oocyte ) can only be made when doing IVF. At this time we aspirate the follicle and check the retrieved oocyte under the microscope. Unfortunately, it's not easy to judge the quality of the oocyte under the microscope, because most eggs are bland spheres with no distinguishing characteristics. In the final analysis, a good egg is one which will fertilise and become a good embryo !

Tuesday, October 13, 2009

Technology infiltrated medicine a long time ago . Doctors are quite savvy and are happy to use advanced technology to improve patient care. Today, all the imaging specialties use computer hardware and imaging processing software routinely . So why don't doctors use EMRs and practise management software routinely to take care of their patients ? Isn't it sad that while hotels use specialised software programs routinely to provide hospitality to their customers, most hospitals are still stuck in the pen and paper stage - forget about individual clinics and doctors. In fact, most doctors use their PC just for word processing and sending email - which means that this powerful electronic brain sitting on their desktop is very poorly utilised.

This is is a hangover from the old days when computer programmers expected doctors to change their habits, so they could use the complicated programs they wrote. These program were never designed to be simple to use; and were very inflexible. Traditionally, this was a result of the way they were built. Some hotshot doctor would hire a programmer who would design a database in Visual Basic for his clinic, so the doctor could start capturing data electronically. While this worked well for the doctor because the program was customised to suit his workflow, when the programmer tried to get other doctors to use the same program, he encountered considerable resistance, because each doctor has his own working style and is very reluctant to change it. While it was possible to change the user interface or to adapt this, this required the programmer to sit down with the doctor and to make the changes - a time consuming and expensive exercise, which is why medical practise management programs never became popular.

The earlier generation of medical practise management software programs suffered from the following defects.

1. Unfriendly and complicated user interfaces: Programming languages were hard to master , and doctors had to hire programmers to write the programs for them. Because doctors are not workflow experts, the software was often designed badly and was unnecessarily complicated. The programs dictated rigid work flows and telling doctors what to do has never worked well !2. Large learning curves: Doctors are busy people and don't really have time to learn how to use a program - especially if it is complicated or not designed to match the doctor's work flow3. Complex system requirements: The software worked well only on high end PCs . These were expensive and doctors were not willing to make this investment.4. Very narrow capability: The software was so specialised and did such specific tasks , that it required two separate programs to manage the clinic ! For example, one program did appointment scheduling only and the doctor needed to buy another program for billing or for writing prescriptions !5. The programs were expensive. Because the market was limited ( not many doctors owned a PC), it was not possible to sell many copies of the program. However, the development costs needed to be recovered, which is why the programs were very expensive and not cost effective.6. Uneducated staff. The administrative modules of the software had to be used by the clinic staff. Often, they were not clever enough to use the software properly - and without training, most of them preferred to abandon it and go back to using paper and ink. They would then bad-mouth the program to the doctor, claiming it was user-unfriendly.7. Lack of portability; The programs ran only on desktop PCs and LANs, which meant that when doctors needed to travel from clinic to clinic, they could not carry their programs with them on their laptops.8. Poor customer support. Doctors were never willing to invest in high end products, as a result of which the companies were often forced to skimp and cut corners. They were unable to hand-hold the doctor or his staff, and could never provide adequate training or after sales support, beause of wafer-thin profit margins. As a result, many software companies were forced to shut down , leaving the poor doctor high and dry - and with an unhappy opinion of the software industry as a whole!9. Poor profitability because of poor sales .It was always hard for the software companies to scale up and become profitable because providing sales and support was expensive and involved travelling and troubleshooting in the doctor's clinic. Today , thanks to the internet, it's now possible to provide demos, videos and help online. This saves the dctor's time and also allows the company to provide effective customer support inexpensively , efficiently and effectively ! 10. Bad word of mouth. Because so many doctors burnt their fingers buying programs which never worked well, many of them simply gave up on the practise management packages, as a result of which all innovation and progress was stifled for many years.

Today , a new generation of doctors which has cut its milk teeth on computers is finally waking up to the fact that well-designed software can be used intelligently to help them manage their practise better. Programming languages have improved, and the software is designed to adapt to the working style of the doctors , using clearer process mapping. Because computers have become cheap and broad band internet easily available, software companies can now sell ther products in large numbers, so that it's possible to provide these programs inexpensively, making them a cost effective investment for the doctor. This confluence of factors means that the market for practise management programs and EMR for doctors is ready to explode in India !